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One Patient, One Chart, One Imaging Record,
a Journey to Simplification
Brad Cook
September 12, 2018
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Agenda
• Who we are – UNC Health Care
• Our EHR Vision and Journey to Enterprise Imaging
– EHR Vision and Governance
– Enterprise Imaging Vision & Execution
• Enterprise Imaging Model
• Governance framework
• Portfolio Simplification
• Achievements to-date
– Future Considerations
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Who We Are – UNC Health Care
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Integrated, not-for-profit health care
system, owned by the State of North
Carolina and based in Chapel Hill.
We provide comprehensive patient
care, facilitate physician education
and research excellence, and
promote the health and well-being of
all North Carolinians.
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Key Stats 2016
Net patient
revenues$4.6B
Licensed beds >3,400
Employees >30,000
Medical staff >5,400
Employed MDs >2,900
Surgeries >105,000
ED visits >430,000
Clinic visits >2.3M
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Orange
Caswell Person
Granville
Vance
Warren
Franklin
Northampton
Halifax
Ala
mance Durham
Wake
Chatham
Nash
Edgecombe
Wilson
Johnston
Wayne
Lee
Moore
Harnett
Sampson
Duplin
Pender
New Hanover
Brunswick
Columbus
BladenRobeson
Cumberland
Hoke
Scotland
Guilford
Randolph
Montgomery
Richmond
Stokes
Forsyth
Davidson
Rowan
Stanly
AnsonUnion
Mecklenburg
Cabarrus
IredellDavie
Yadkin
Surry
AlleghanyAshe
Wilkes
Alexander
Catawba
Lincoln
Gaston
Cleveland
Burke
Caldwell
Watauga
Avery
McDowell
Rutherford
Polk
Mitchell
Yancey
Buncombe
Henderson
Transylvania
Haywood
Madison
Swain
Jackson
Macon
Graham
Clay
Cherokee
Onslow
Jones
Lenoir
Greene
Pitt
Martin
Bertie
Hertford
GatesCamden
Pasquotank
DareTyrrellWashington
Beaufort
Hyde
Craven
Pamlico
Rockingham
Currituck
Perquimans
Chowan
Carteret
We serve North Carolina. Every day.
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Vision of One … Established in 2012for Enterprise EHR
2013(January – March)
• Planning and Guiding Principles
• Core Team Assembly and Training
• Subject Matter Expert - SMEs
• Key Decisions
2014 Go-Lives(April 4th Go-Live 1 and June 20 Go-Live 2)
• 3 Hospitals: UNC Hospitals; Chatham Hospital; Rex Hospital
and
• All their Physician Groups (Rex, UNCPN, UNC Faculty)
EHR@UNC
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Vision of One continued as UNC Health Care grewSo, did the challenges with a very diverse application portfolio
2015 Go-Live(May and June)
• New Ambulatory Clinics across 3 Hospitals – Caldwell, Johnston, High Point Regional
• EHR Optimization (Improving Existing Build)
2016 Go-Lives(May and June)
• 4 New Hospitals – Caldwell, Pardee, Johnston, HighPoint Regional
• Cardiology Module – all entities
• Lab Module – all entities
2017 Go-Lives(Oct – New Modules – all entities)
• Case Management
• Infection Control, Antimicrobial Stewardship
• Transfer Center
2018 Go-Lives• Homecare and Hospice Module – all
entities
• 2 New Hospitals – Nash and Wayne
EHR@UNC
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Backed by Governance
Guiding Principles: EHR@UNC’s “Constitution”
Mid Level Decisions
HighLevelDecisions
Detailed Decisions
~ 25% of decisions (moderate
impact)
~ 10% of decisions
(major impact)
~ 65% of decisions
(local impact)
Work Groups and Design Session
participants:
e.g., verbal order workflow definition
Design Teams:
e.g., decision to enter patient age or
date of birth
Executive and Steering Committees:
e.g., parameters of “localization” allowed
• Guiding PrinciplesCascading sponsors
and example of decisions:
Guiding Principles frame the design decisions to be made by the Work Groups and the Design Teams at large.
They are important as they support an efficient and empowered, decentralized decision-making process needed
to support EHR@UNC’s accelerated timeline
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UNCHCS Senior Executive Team
Information Systems Oversight Committee (ISOC)
Work Groups
Sub-Work Groups
Core Team
(Analysts)
Design Team
(SMEs)
Oversight Committee reviews
progress from the
Workgroups. Resolve
remaining conflicts
Escalate design/ standardization
decision conflicts, or potential changes to policy and practice
Workgroups working in conjunction
with Sub-Work Groups identify
decisions required to change current
clinical policy and clinical practices -
presented as a consensus agenda to
communicate all decisions that
change current processes.
Establish direction for Design Teams
Guide policy adoption
Approves budget/ SBAR’s
Define Vision and Goals
Define Guiding Principles
Define Key Decisions
Working with Core Analyst Teams,
Design Teams make design decisions
based on their decision rights
Sub-Work Groups resolves
conflicts from Design Teams,
approves change
recommendations. Escalates
to Work Groups as needed.
“Decision Rights”Delegation
Conflicts Escalation
Delegation & Escalation
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Str
ate
gic
UNCHS Senior Executive Team
UNCHS Information Services Oversight Committee
(ISOC)
Business & Rev
Cycle Work GroupClinical Work
Group
Research,
Analytics &
Reporting Work
Group
HCS Growth &
Expansion Work
Group
Innovation
Work Group
Enterprise Architecture,
Infrastructure & Security
Project Management Office
IT Leadership
Daily IT
Operations
(~70-80% of
resource
consumption)
• Strategic Initiatives
• System Imperatives
• Entity Committees
• Operational Committees
• Senior Leadership
• Service Requests
• Other Informal Requests
Request Intake & Initial Triage Requests
Supported by Operational &IT GovernanceIT Governance evolved to keep up with growth…
Tactical
Sub-Work Groups
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“Enterprise” Image Enabling the EHR
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One Patient One Chart didn’t address Enterprise Imaging
Imaging Strategies were Service Line focused and Facility based with
• IT infrastructure complexity; BC/DR planning challenges
• Immature imaging strategy and practices outside of Radiology and Cardiology
• With inability to exchange images
• Proliferation of stand alone point of care devices with no image retention
• Trying to turn EHR into an Imaging Repository
• No Enterprise Image Lifecycle Management Policy for electronically stored media
It only got worse with Health System growth
• 32 Systems in Imaging and Reporting Portfolio just across Radiology and Cardiology
• Not counting specialty systems
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Where we wanted to go
• Improved Access to Images across the
UNC Health Care enterprise
• Compliant and secure Data Sharing
• Reduced Management Complexity
• Interoperability and Data Exchange
• Sophisticated ILM Strategies
• Lower Total Cost of Ownership
• Take Back Control
Centralized
Secure
Image Lifecycle Management
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With new entities and a growing demand for new technologies…
Enterprise Architecture was bornPortfolio Simplification was first major initiative, and Enterprise Imaging a Major Focus Areas
Enterprise Architecture Mission and Focus
To compose holistic solutions that address enterprise business challenges
and support the governance needed to implement them
Establish IT solution roadmaps and blueprints for effective and efficient
enterprise solutions that will serve the business now and the future
Focus:
• Evangelize the “Enterprise” Perspective
Enterprise viewpoint, Interoperability focus, and Take the long-view (when appropriate)
• Increase Agility of IT
Consultant and “trusted advisor”, Proactive (get ahead of needs), and Adapt services
and solutions to meet the needs
• Foster Innovation
Build a body of knowledge, develop standards, define repeatable patterns to spend
more time on innovation
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Consolidate over time
Enterprise Imaging ModelCore Vision Achieved
Enterprise EHR
Web Viewer
Enterprise Imaging Solution
Vendor Neutral Architecture (VNA)
Multiple PACSDepartmental
Imaging Systems
Medical
Devices
Image Life Cycle Management
Tiered Storage – Long-term Retention
Modalities
Mobile
Devices
Image link to one
Enterprise Imaging solution
Partially Done
Complete for UNC EHR entities
External
Images
Future phase
Vision Expanded in 2017
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Enterprise Imaging Vision bundled with Portfolio Simplification
Vision endorsed by CEO roundtable, ISD Governance and Imaging Consortium
• Support for Portfolio Simplification had to come from the Top
• Carolina Value re-endorsed Portfolio Simplification
Enterprise clinical imaging strategy:
• Enterprise Imaging Model plan to drive strategy
• Not limited to Imaging Department areas
• Workflow improvement, compensating controls and image integrity was key
• Simplify Imaging Systems Portfolio
• Platform to promote innovation
Interdisciplinary team established to select an Enterprise Solution
• Led by Physician Chair and supported by IT Enterprise Architecture
• Initial Implementation Scope driven by Portfolio Simplification
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Turning Vision into Action
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Clinical Governance – Critical Foundation
Enterprise Radiology and Cardiology workgroups established to make key decisions
during enterprise EHR rollout still continue
• Physician and Executive Sponsors established to drive standardized workflows, and prioritize
optimizations
• Examples: Lung Screening, Palette optimizations, specialist participation for Bi-Rad
combinations
• Set the stage for more expansive enterprise imaging clinical governance
• Not just VNA, but all Imaging Solution decisions
System selection team primarily providers and clinical department representatives
• ISD co-chaired to support the clinical vision
• Group established project scope for initial rollout
Enterprise Imaging Workgroup established post rollout
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Clinical Enterprise Imaging Workgroup added under ISD
Governance Structure
Clinically Led, IT Supported
Functions as a platform for
• New project request review and approval
• Design decisions
• Prioritization when needed
• Promoting innovation
Collaborates with Imaging Consortium on
• Imaging product decisions
• Image Life Cycle Management decisions including Enterprise Image Retention Policies
Works within ISD Governance
• Integrating tightly with processes like IT Enterprise Architecture
• Focusing on workflow improvement, compensating controls and image integrity
• Continuing to support and expand the Enterprise Imaging Vision
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Adoption has led to significant gains
Benefits realized … Journey continues
Supports the One Patient One Chart Vision
Operational Efficiencies and Compliance
Reduction in annual support and enhancement costs; Fewer upgrades; and More
efficient support models
Architecture Simplification
Fewer interfaces; Fewer server and application foot prints; Focus now on business
continuity planning
Tighter Clinical Integration & better continuity of care
Examples:
• Timely access to images across enterprise facilitates time-sensitive consults with
rest of UNC Health Care System
• Reduction in repeat imaging tests
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VNA MetricsSince then, we have accomplished the following in parallel with EHR rollout for 6 hospitals &
related clinics
44 ClinicsImage Enabled Ambulatory Clinics with Radiology / Cardiology
Imaging Equipment
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Simplification
Eliminated 9 PACS and 3 Reporting/Dictation systems
6 More planned for Replacement in 2018
31 POC
AreasDepartments & Functional Areas live on POC integration to VNA
600 Users/hr600 users per hour viewing exams with enterprise viewer during
the work day
9.4 Million 2.5 million exams archived to VNA over the last 24 months
6.9 million legacy studies converted and archived
1Image
RepositoryImplemented VNA w/Universal Viewer integrated with EHR,
providing a Longitudinal Image Record
Visible
Light
Enabled VNA for Visible Light Image Capture and Storage via EHR
smart phone/iPAD module, also providing Longitudinal Image
Record for those images
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What’s Next
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Enterprise Imaging Vision Realized and Expanded
+Extended the spirit of One patient, One Chart
to
One Clinical Enterprise Image Repository (Acuo VNA)
integrated with Enterprise EHR
Via One Common Viewer (Nil Read)
+Cloud Image Exchange
& HIEs
Enterprise EHR
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VNA / Nil Read Viewer
1Image
RepositoryImplemented VNA w/Universal Viewer integrated with EHR,
providing a Longitudinal Image Record
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VNA / Nil Read Viewer 3D
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VNA / Nil Read Viewer
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Dose Treatment Plans VNA / Nil
PDF stored in VNA
Nil DICOM-RT overlay
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UNCHCS Clinical Viewer Updates
Nil Tip sheet available on intranet - http://intranet.unchealthcare.org/epic/files/2017/nil
LMS Training – Activity Code HCSNILTRAIN
Log ticket though MySupport@UNC or call the Service Desk
© 2018 Epic Systems Corporation. Used with permission
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Combining EHR + PACS Scan Web + Nil
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Visual Light Imaging Web Tools
Standalone web-based tools offer flexibility for various use cases including restricted photos
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Combining Modality + PACS Scan Image Link
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Visual Light Imaging Mobile
Coming Soon: Button in Haiku / Canto / Rover to launch PSM
Imaging in the mobile arena is becoming more popular. Apps are integrating with cameras on tablets and phones
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Future of Enterprise Imaging at UNC Health Care
Continue the Journey … Image enabling all applicable areas across the
Enterprise
Optimize and Focus on Image Life Cycle Management
• Better tools needed for Image Integrity
Support the Enterprise Growth …
• 2 More Hospitals Planned for ISD on-boarding in 2018
• New EHR Modules being added in 2018 and 2019 require Imaging
Focus on Innovation and Telemedicine Support
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Convergence of Enterprise Content Management and Clinical Imaging
Enterprise Imaging Future at UNC Health Care
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New innovative uses of Artificial Intelligence applications
Enterprise Imaging Future at UNC Health Care
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Open Discussion & Questions
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Contact Information
Brad Cook
HCS-Application Developer ISD Clinical Imaging
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